-Definition: Hemorrhoids are engorged fibrovascular cushions lining the anal canal.
-DDx: Anal canal cancer; Colorectal Cancer; Anal fissure; IBD; Condyloma; Perianal Abscess; Rectal polyp; Cirrhosis/portal hypertension
-Predisposing factors: “Older age, constipation, straining (including exercise), gravity, lack of dietary fiber, increased intra-abdominal pressure (due to pregnancy, obesity, or ascites), multiple vaginal deliveries, irregular bowel habits (constipation/diarrhea), family history, and functional venous insufficiency within hemorrhoidal veins.” AAFP
-Prevalence: About 50% of Americans 50 years or older have some hemorrhoid-related symptoms. 1 in 20 Americans of any age has hemorrhoids. They are more common between 45 years and 65 years.
-Presentation: Most common presentation is bright red, painless rectal bleeding during defecation.
Treatment
–Pharmacotherapy for symptomatic hemorrhoids in adults. In addition, do the following.
–High fiber diet: Increase dietary fiber and water intake to soften and bulk the stool. The recommended dietary fiber intake is between 20 and 35 grams per day.
–Fiber supplements: If the patient is still constipated after dietary fiber, take either psyllium husk (Metamucil), or methylcellulose (Citrucel), or wheat dextrin (Benefiber), or calcium polycarbophil (Fibercon). Take as directed.
–Drink lots of water with the fiber: At least 2 Liters or 67 ounces per day. That is eight 8-oz glasses of water.
-Take a stool softener or laxative: If a fiber supplement is not sufficient, take a stool softener or a laxative like Colace or Miralax.
–Sitz bath: Warm sitz baths about 10 to 15 minutes 2-3 times per day and after each BM will relax the anal sphincter and improve blood flow to the anal mucosa facilitating healing. Get Sitz bath kit or portable bowl from a drugstore. A bathtub may be used for a sitz bath by filling it with 2-3 inches of warm water. Don’t add soap and bubble bath. Wipe thoroughly with a towel or blow dry after each sitz bath.
-If nonsurgical management is unsuccessful, will do rubber band ligation which is the most effective office-based procedure for grades I, II, and III hemorrhoids.
-Surgical hemorrhoidectomy will be used after failure of nonsurgical management and office-based procedures and also as initial management for grades III and IV hemorrhoids.
-For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, will be the optimal management.
–Prolapsed and strangulated hemorrhoids will be best managed with stool softeners, analgesics, rest, warm soaks, and ice packs until recovery; residual hemorrhoids will be banded or excised later.
-Colonoscopy at age 50.
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Classification of hemorrhoids. See here.
Hemorrhoids are classified into 3 categories based on anatomic location:
– Internal hemorrhoids are insensate and located above the dentate line (anal valves).
– External hemorrhoids are sensate and located below the dentate line.
– Interno-external hemorrhoids cross the dentate line.
“The appropriate management of a thrombosed hemorrhoid presenting within 72 hours of the onset of symptoms is elliptical excision of the hemorrhoid and overlying skin under local anesthesia, such as 0.5% bupivacaine hydrochloride in 1:200,000 epinephrine, infiltrated slowly with a 27-gauge needle.
Incision and clot removal may provide inadequate drainage, resulting in rehemorrhage and clot reaccumulation. Most thrombosed hemorrhoids contain multilocular clots that may not be accessible through a simple incision. Rubber band ligation is an excellent technique for management of internal hemorrhoids, and infrared coagulation is also used for this purpose. Banding an external hemorrhoid would cause exquisite pain.
If the pain is already subsiding or more time has elapsed, and if there is no necrosis or ulceration, measures such as sitz baths, bulk laxatives, stool softeners, and local analgesia may be helpful. Some local anesthetics carry the risk of sensitization. Counseling to avoid precipitating factors such as prolonged standing/sitting, constipation, and delay of defecation is also appropriate.” ABFM
Resources
http://emedicine.medscape.com/article/775407-clinical#b4
http://www.aafp.org/test/fpcomp/FP-E_419/fpe419-pt1.html
http://www.aafp.org/afp/2012/0315/p624.html
J Fam Pract 2009;58(9):492-493.